FALL DATA COLLECTION INSTRUMENT Case ID: MI Date of Investigation / / Respondent Victim Information 1. Was the victim performing a task that was not a part of their normal work duties/tasks? 2. Was anyone within direct visual or verbal contact with victim at the time of the incident? 3. Was this direct contact maintained for safety purposes? 4. How familiar was the victim with the task being performed at the time of the incident? 5. How often did victim do this task? (if variable amounts, ask about the month prior to the incident) 6. How long had it been since the task was last performed by the victim? 6a. NOTES: (Go to Q4) 01. Not familiar 03. Very familiar 02. Somewhat familiar 01. First time ever? 05. One or more times per 02. Less than once per week week 06. Daily or almost daily 03. About once per 07. Monthly month 08. Other 04. Sporadically (during a month) 01. < 1 week before incident 02. > 1 week before incident 03. 1 month before incident 04. 6 months to 1 year before incident 05. >1 year before incident 06. Earlier in day 07. Other Incident Information 7. The victim s work area at the time of the incident was: (circle all that apply) 01. Usual work area 02. Unfamiliar work area 03. Limited Access work area 04. Restricted work area 05. Unauthorized work area 06. Authorized work area 1 of 7
8. Check all that apply concerning the victim s activity preceding the fall. 9. What was the direction worker moved prior to fall? 01. Using tools or equipment 02. Lifting, carrying, moving objects 03. Walking 04. Running 05. Transported by vehicle, lift, etc. 06. Utility service work 01. Forwards 02. Backwards 03. Sideways 04. Up 10. What was the event that preceded the fall? 01. Work surface collapsed 02. Victim slipped/tripped 03. Equipment failure 04. Victim lost balance/grip 11. What were the environmental conditions that existed at the time of the incident? (Check all that apply) 12. What were the fall hazard warnings at the incident site? (Check all that apply) 13. Before work began, was a site survey conducted by a competent person qualified to identify potential hazards and determine appropriate control measures? 01. Poor lighting 02. Dust 03. Glare 04. Fog 05. Sunlight 06. Wind 07. Rain 01. Warning lines 02. Warning signs 03. Perimeter barrier 07. Climbing 08. Steel connection 09. Carrying object that obstructed sight 10. Other (specify) 9 05. Down 06. Other (Specify) 05. Walked into opening 06. Other (specify) 9 08. Noise 09. Artificial lighting 10. Working at night 11. Hot conditions 12. Freezing conditions 13. Other (specify) 04. No warning 05. Other (specify) 06. NA 14. General Incident Description: (Provide a brief detailed description of the activities being performed by the victim (pre-event, event, post-event) 2 of 7
CORE INFORMATION FALL (Transfer to CORE INFORMATION, page 4, Q57-61) 57. Reason for fall 01. Slipped/tripped 02. Pushed 03. Jumped 04. Structure gave way 58. Distance worker fell 01. ft in 59. Surface worker fell from or through: 01. Ground surface or floor 02. Scaffold/ladder 03. Walkway/catwalk 04. Unguarded roof opening 05. Roof edge 06. Structural steel 07. Piled/stacked materials 60. Surface worker fell to: 01. Loose soil 02. Packed dirt 03. Wood surface 04. Water 05. Roadway 06. Concrete, rock, asphalt 07. Metal Surface 61. Working surface conditions at the time of the incident (Circle all that apply) 01. Dry 02. Wet 03. Frost/ice/snow covered 04. Damaged or worn 05. Medical condition 06. Other (specify) 08. Vehicle, machinery or equipment 09. Tree 10. Skylight 11. Other (specify) 08. Boxes, objects, work materials 09. Carpeted or tiled flooring 10. Other (specify) 05. Cluttered 06. Not properly secured 07. Other (specify) 08. Other (specify) 3 of 7
Company Safety Program 15. Were safety issues discussed with victim prior to starting the day s work? 16. Were safety issues discussed during the planning and design phases of the project? 17. What components of a fall protection system, designed to prevent an employee from a free fall were in place? (Check all that apply) 18. Was there a malfunction of any component of the fall protection system? 19. Describe malfunction 01. Guardrails/handrails 02. Safety Net system 03. Personal fall restraint systems 04. Positioning device system 05. Warning line system 06. Safety monitoring system (Go to Q20) 07. Controlled access zone 08. Covers for walking/working surfaces 09. Ladder cage 10. NA 11. None 9 (Go to!20) (Go to Q20) 20. Was there a written fall protection plan documenting the reasons why the use of conventional fall protection systems (guardrail systems, personal fall arrest systems, or safety nets systems) are infeasible or why their use would create a greater hazard? 20a. NOTES: Personal Protective Equipment 21. What types of PPE does the company require employees to use while performing the task: (Circle all that apply) 01. None 02. Hard Hat 03. Lifeline 04. Lanyard 05. Full body Harness 06. Safety Belt 22. Was victim using PPE? (Go to Q28) (Go to Q28) 23. What types of PPE was victim using: (Circle all that apply) 01. Hard Hat 02. Lifeline 03. Lanyard 04. Full body Harness 05. Safety Belt 24. Was PPE used in accordance with its design and function? 25. Was the type of PPE used sufficient to protect him/her? 26. Did the PPE malfunction? (Go to Q28) (Go to Q28) 07. Safety Net 08. Straps 09. Locking type snaphooks 10. NA 11. Other (specify) 9 (Go to Q28) 06. Safety Net 07. Straps 08. Locking type snaphooks 09. Other (specify) (Go to Q28) 4 of 7
27. If yes, briefly describe PPE malfunction 28. Did employer maintain and inspect fall (END) protection systems on a regular basis? (END) (END) 29. Date of fall protection equipment inspection 01. / / Guardrails/handrails 02. / / Safety Net system 03. / / Personal fall restraint systems 04. / / Positioning device system 05. / / Warning line system 06. / / Safety monitoring system 07. / / Controlled access zone 08. / / Covers for walking/working surfaces 09. / / Ladder cage 10. / / Hard Hat 11. / / Lifeline 12. / / Lanyard 13. / / Harness 14. / / Safety Belt 15. / / Straps 16. / / Locking type snaphook 29a. NOTES: 5 of 7
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